Executive Positions with Managed Care Organizations

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espsonia@pacbell.net
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Contact: Sonia Varian
T 818.707.7118

V.P. OF MEDICAL MANAGEMENT - MS - Will Relocate
Direct and coordinate activities of department and aid the chief officer of the health plan and appropriate corporate staff in formulating and administering organizational and departmental policies. Review analyses of activities, costs, and operations and forecast data to determine department progress toward stated goals and objectives. Perform duties to direct and coordinate the medical management, quality improvement and credentialing functions for the assigned health plan based on, and in support of the company’s strategic plan; establishing the strategic vision and attendant policies and procedures.
Equivalent to a four (4) year education in nursing. Advanced education in nursing, health care, business or public administration preferred. Thorough knowledge of a specialized or technical field such as clinical nursing, managed care, and healthcare administration. Familiarity of case management practices, managed care, and Medicaid programs. Familiarity of National Committee on Quality Assurance (NCQA) accreditation process and standards.

VICE PRESIDENT OPERATIONS – MS - Will Relocate
Perform duties as chief liaison between the identified region and Corporate policies & standards. Facilitate operational oversight for multiple departments and identify opportunities for maintaining the most cost efficient operation. Identification of operational efficiencies; meet regulatory and client expectations and develop a “best practice” approach to all operations. In support of the overall strategic plan, establish operational strategic vision, objectives, policies and procedures for the Plan. Meet and exceed requirements including organizational, state, compliance and contractual agreements. Ensure cost effective, client and employee responsive programs are developed and maintained throughout the Plan. Oversee all operations for the defined region, including responsibility for Profit & Loss.
Bachelor's degree in Business Administration, Healthcare Administration or equivalent. At least 8 years of experience in Management, Administration or Operations in the Healthcare or Insurance industry. Master’s degree preferred.

V.P. COMPLIANCE - GA - Will Relocate
Ensure regulatory compliance with state Medicare, Medicaid program and state health care cost containment activities for the state health plan, of the Corporation and its business subsidiaries. Develop and maintain records of Medicare and Medicaid contracts, contract amendments, compliance measures and improvements, policy, procedure and process documentation. Develop policies, procedures and processes to comply with state law, federal law and state contract requirements. Train health plan staff of new policies, procedures and processes to comply with new state law, federal law and state contract requirements.
Requires a Bachelor's degree in Public Policy, Government Affairs, Business Administration or equivalent. At least 5 years of relevant experience. Extensive knowledge of state administrative code and regulations, Medicare, Medicaid and state insurance laws and regulations including managed care regulations. Experience with state and federal government agencies, accreditation bodies, participating provider agreements, HIPAA and Third Party Administration (TPA) laws, credentialing regulations and prompt pay laws. Master’s or Law degree preferred. Current Management experience required.

DIRECTOR OF MANAGED CARE - Florida
Responsible for the day-to-day operations of Florida Managed Care health plan including Medicare and Medicaid lines of business. Assures timely reporting of required information to the Managed Care Division, Finance Department, Managed Care Executive Committee, Senior Management, Board of Directors and contracted private and/or governmental agencies. Assures all contractually required reports from the Florida lines of business are submitted to the appropriate agencies. Develops relationships with key service providers and vendors to facilitate collaboration and growth of the managed care programs. Ensures the annual Business Plan is implemented and monitored, including documented departmental and overall managed care goals and objectives. Oversees the management of all departments operations. Provider Relations, Contracting and Network: Quality Improvement, including Credentialing, Development/Maintenance, Claims Administration, Member Services, including enrollment/disenrollment and regulatory required member and provider materials. Utilization and Case Management, Clinical Compliance and Informatics, Medical Director/Medical Management policy, MIS managed care operations.
Education and Experience
Bachelor’s degree in Health Care, Public or Business Administration or related field required. Masters degree preferred. Minimum 10 years experience with managed care overall, with at least 5 of those years in a management role. A background in Medicaid or Medicare managed care strongly preferred.

SALES MANAGER - Health Plan - So. California
Sales Manager, in collaboration with the Director of Sales manages and develops the staff and processes directed toward the enrollment of eligible individuals to Managed Care Plans in CA. This includes Community Outreach and marketing efforts, direct-to consumer marketing and/or counseling, development of relationships with contracted providers and collaboration with Information Systems, Case Management, Provider Relations and Contracting and Member Services Departments to ensure the highest level of customer satisfaction.
General Essential Duties & Responsibilities. Knowledge and demonstrated competency in interpreting, developing, executing and maintaining marketing and sales activities within the regulatory and contractual requirements of The Centers for Medicaid and Medicare Services (CMS) Medicare Advantage Part D plans. Maintains all necessary sales/enrollment licensure or accreditations required by CA - Medi-Cal or Medicare.(e.g., Licensed California Insurance Agent). Ensures that all other sales staff do the same. Develops, ensures appropriate approval, implements and maintains policies, procedures and materials for sales and marketing that meet federal, state and contractual requirements. Motivates self and enrollment team to meet or exceed enrollment activity targets.
Certificates, Licenses and Registrations
Valid California Driver’s License with proof of liability insurance.
California Insurance Agent Licensure

COMPLEX CASE MANAGER
Health Plan - Excellent Compensation
Telecommute – on Site Case Management – Location: Stockton

To conduct telephonic and on-site case management and in a collaborative process of assessment, planning, facilitation and advocacy for options and services required to meet an individuals heath needs, using communication and available resources to prevent readmissions and promote quality, cost-effective outcomes. Builds effective business relationships with members and other internal and external partners. Selects appropriate cases to open by screening from internal or external referral sources. Manages cases by using essential activities of case management including assessment, planning implementation, coordination, monitoring and evaluation.
Promotes patient empowerment during care transitions by assisting the patients/caregiver to develop skills to advocate for themselves. Facilitates member care being delivered at the right level, right place, right time according to the benefit plan by acting as a resource to case managers, physicians and other member's health care team providers. Timely written documentation shows evidence of all CCM and Care Transitions activities and provides a status of the case for all of the internal case management team.
Facilitates qualify of care and service by referring any potential quality issue to the Medical Director and Medical Management Department.
Registered Nurse (Current and active California RN license in good standing)
Case Management Certification preferred.
Three to five years experience in medical-surgical nursing.
Three years concurrent review / case management experience in the managed care industry required.

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